Homoparenting as a public health issue: a scoping review

ABSTRACT OBJECTIVE To map global scientific production on homoparenting in the field of collective health or public health. METHODS In terms of methodological procedures, a scoping review was carried out, guided by the following question: What are the aspects addressed in global scientific production regarding homoparental families in the field of collective or public health? The searches were carried out in seven sources of scientific literature, including 58 studies, involving scientific articles and dissertations. The analytical treatment given to the studies, most of which were qualitative, followed the content analysis technique in the thematic modality. RESULTS The results indicate that the perceptions of homosexuals and professionals about the care provided and health services in general was the topic addressed by the largest number of studies (n = 31), followed by heteronormative context of health services (n = 26); disclosure of sexual orientation (n = 20); fertilization (n = 14); educational information and actions (n = 5). CONCLUSION Although the issue of same-sex parenthood has been discussed in some health sectors, there is awareness that it is necessary to rely on a consolidated basis through numerous studies when discussing this issue. It is concluded that, among other aspects, the scope of this review is not sufficiently problematized within the scope of health professionals’ training and performance.


INTRODUCTION
The family has been one of the central focuses in several instances of public health.As an example of this, the Family Health Strategy stands out, one of the models for organizing services in the Brazilian Unified Health System (SUS).In this and other instances, the commonly used family reference is the traditional model, which originates from the union between a cis man and a cis woman.This union establishes, in the contexts, texts and relationships of the health area in general, the hegemony of heterosexual parenting, disregarding homoparenting or same-sex parenting, which is the theme of this article.
In order to discuss same-sex parenting, it is necessary-based on anthropological studiesto take into account that the types of relationships considered as family can be seen in different ways within their own societies, not being limited to genealogically defined relationships 1 .Considering the different types of relationships, gay and lesbian families can include lovers, co-parenting, adopted children, children from a previous relationship, and children conceived through alternative insemination 1 .
Although the issue of same-sex parenting has been discussed in some health sectors, the need to have a consolidated base with numerous studies when problematizing this issue is well-known.One of the dimensions to be covered is the formation of an analytical framework, considering the specialized literature, that can serve as a reference for incorporating the discussion about the object of study both in the logics and in the scenarios of collective health practices.
Zambrano 2 notes that: Homo-parenthood is a neologism, created in 1997 by the Association of parents and future gay and lesbian parents (APGL), in Paris, nominating a situation in which at least one adult refers to themselves as homosexual who is or wishes to be a father or mother of at least one child.(p.127; our translation) 2 .
Ribeiro et al. 3 (p.3592), based on Zambrano 2 , observe that homo-parenthood is constituted from at least four situations: […] by children born in a previous heterosexual relationship, by legal or informal adoption, by the use of new reproductive technologies that enable the birth of biological children, and by coparenting, in which care for the child is exercised in a joint and egalitarian way by partners 3 (p.3592; our translation).
With the aim of placing same-sex parenting in the context of the changes that have been taking place in the family institution, it is observed that the patriarchal family has been questioned since the end of the last millennium.In recent years, the dissociation between heterosexuality, patriarchy and reproduction of the species reinforced the gay and lesbian movement's struggle to have legal recognition of getting married, starting a family, and having children 4 .
In line with this claim, the exclusivity of having a cis man and a cis woman to form what is called a family is questioned, so that if the bond of affection is considered central to the family institution, the union between people of the same sex can be considered as family 5 .
Although the discussion of the subject is not new, it is inferred that-in the health area in general in Brazil-publications on same-sex parenting are scarce.A concise survey, carried out on July 7, 2021, with the expressions "homoparentalidade AND saúde," found only two articles in the Scientific Electronic Library Online (SciELO) and four in the Portal Regional da Biblioteca Virtual em Saúde (BVS).
Clearly, these quick surveys do not represent the state of the art of the subject within the scope of Brazilian scientific production, requiring more in-depth searches, in a systematic way, with a wide range of databases.
In this sense, a scoping review is proposed to be carried out, with the aim of mapping global scientific production on homo-parenthood in the field of collective health or public health.
In Brazil and in some Latin American countries, there is a difference between collective health and public health.The former, according to Paim 6 , refers to a field integrated by knowledge, practice, and ideology, differentiating itself from both public health and the hegemonic medical model and articulating science and practices for the formulation and conduct of consequential policies.Thus, the collective is not just an abstract population or population segment, and actions aimed at the collective are not exclusive to the State.In the international panorama, in general, the term collective health does not appear, but rather public health, which encompasses measures designed and adopted mainly by the State to ensure the population's physical, mental, and social well-being.In this sense, the scope of this review is analyzed in the realm of collective health or public health so that production is not reduced to the Latin American sphere.

METHODS
We carried out a scoping review based on the methodological framework of the Joanna Briggs Institute 7 .For the reporting of this review, the recommendations of the PRISMA Extension for Scoping Reviews 8 tool were used.A research protocol has been registered in the Open Science Framework (OSF) 9 .

Research Question
The question "What are the aspects addressed in global scientific production regarding homoparental families in the field of collective or public health?"was constructed with the help of the acronym PCC (Population: cisgender homoparental families; Concept: global scientific production; Context: collective or public health).We decided to work with an open and broad question to obtain a greater diversity of scientific production on the subject.

Inclusion and Exclusion Criteria
The inclusion criteria were primary and secondary studies, including documents, reports, dissertations, or theses, available in English, Portuguese or Spanish, which addressed issues related to policies, health programs and access to services for cisgender homoparental families in the context of public health or public.
Studies that referred to contexts other than collective health, that analyzed configurations of non-cisgender same-sex families, or that were in languages other than those mentioned above, were excluded.

Data Sources and Search Strategies
The construction of strategies and the searches were carried out by a librarian in the following data sources: PubMed/MEDLINE, Literatura Latino-Americana e do Caribe em Ciências da Saúde in the Virtual Health Library (VHL/LILACS), SciELO, Scopus, Web of Science, Dimensions (July 2022), and Biblioteca Digital Brasileira de Teses e Dissertações (BDTD) (September 2022).Based on the combination of keywords structured from the acronym PCC, the MeSH terms (Medical Subject Headings) were used in PubMed and DeCS (Health Sciences Descriptors) in the VHL, adapting them to the other databases.The search strategies with the keywords used in each database are available in the protocol of this review registered in OSF 9 . https://doi.org/10.11606/s1518-8787.2023057005447

Study Selection
The studies retrieved from the information sources went through a selection process based on pre-defined inclusion and exclusion criteria.After excluding duplicates, two reviewers independently carried out the screening based on reading titles and abstracts, using the bibliographic manager Rayyan QCRI 10 .Differences in judgment were resolved by consensus or by a third reviewer.Dissertations and theses were selected manually by reading the abstracts.Eligible studies were read in full by two reviewers, in a complementary manner, and validated by a third reviewer.The reference lists of included studies were checked to include other studies that might not have been retrieved in database searches.

Data Extraction
A spreadsheet for extraction was prepared in Excel (Microsoft), containing the following information: (1) Author and year of publication, (2) Purpose, (3) Study design, (4) Population analyzed, (5) Number of participants, ( 6) Age of participants, (7) Sex/gender, (8) Race/color, (9) Family characteristics, (10) Country where the study was carried out, (11) Place where the study was carried out, (12) Focus of the approach and central theme, (13)   20) Institution of affiliation of the author.The first extractions were carried out independently by three reviewers, until homogeneity of the process was achieved.Subsequently, the data were extracted by two reviewers, in a complementary manner, and validated by a third reviewer.

Data analysis
The extracted data was explored to present the state of the art regarding homoparental families in the cisgender population, seeking to report their needs and experiences related to the area of collective health.The results of the studies, mostly qualitative, were analyzed based on the content analysis technique adapted by Gomes 11 from the thematic modality described by Bardin 12 .The results are presented descriptively and through tables.
The methodological quality of the included studies was not assessed because it was not part of the inclusion criteria and is considered optional in scoping reviews 7 .

RESULTS
The searches retrieved 1,350 records and, after excluding duplicates, 725 records were screened by titles and abstracts.Forty eligible reports were read in full, 24 of which were included.Of ten non-duplicated dissertations and theses, two were included.Additionally, 32 reports were selected from the reference lists of the included studies.Therefore, a total of 58 studies were included and analyzed in this scoping review (Figure).The sixteen studies and eight theses excluded are presented in OSF 13 .
Of 58 reports 15-72 , 40 were classified as primary studies (including two Brazilian master's theses) 54,61 , 2 as essays, and 16 as reviews, whose characteristics are briefly described below.

General Characteristics of Primary Studies
Chart 1 shows the main characteristics of primary studies.Regarding design, the studies are qualitative (n = 33), cross-sectional (n = 4), mixed (n = 2), and quantitative (n = 1).Most authors reported that they received financing (n = 19), while others did not receive it (n = 5) or did not report it (n = 16).Half of them reported having no conflict of interests and the other half did not report it.
Most studies involved lesbian women (n = 32), gay men (n = 9), and healthcare professionals (n = 7).When provided, participants' age ranged from 20 to 59 years old, with a predominance of white people.

General Characteristics of Reviews and Essays
The main characteristics of the 2 essays and 16 reviews (2 systematic reviews, 1 metaethnography, 1 clinical guidelines review, 1 integrative review, 1 overview of reviews, and 10 narrative reviews) are shown in Chart 2. The authors reported no conflict of interests (n = 9) or did not provide this information (n = 9).Some studies received financing (n = 5), others did not receive it (n = 3), but most did not provide this information (n = 10).The populations analyzed were lesbian women (n = 16), gay men (n = 7), and health professionals (n = 4).

Mapping the Collection by Themes
When analyzing the collection of selected sources, we observed themes that were implicit or explicit in the contents of these sources (Chart 3).Such themes are not necessarily exclusive.Some of them overlap and others are distinguished by their specificities.
Source: based on Prisma 14 .BDTD: Bank of Theses and Dissertations; VHL: Virtual Health Library; OSF: Open Science Framework.* Excluded studies 13 .The data extracted from the studies were grouped into five themes, presented together with their respective subthemes in Chart 3. Perceptions of homosexuals and professionals regarding care provided and health services in general was the theme addressed by the largest number of studies (n = 31), followed by the heteronormative context of health services (n = 26); disclosure of sexual orientation (n = 20); fertilization (n = 14); and information and educational actions (n = 5).Chart 3. Themes and respective subthemes covered in primary studies, theses, essays, and reviews.

Negative interactions
Absence of emotional support Non-acceptance of non-biological mothers

Constraints and discrimination
Lack of benefits for families headed by one or two homosexual adults Exclusive approach to the biological father

Service denied
Excessive curiosity of professionals

Symbolic violence
Service habits disturbed by the presence of homosexual couples Inappropriate language directed at homosexuals The need for an environment to protect oneself from homophobia

Misunderstanding by professionals
Professionals not prepared to care for homosexual couples Information and educational actions 27,32,39,41,51,71 Positive score for sex education programs Insufficient information on induced lactation for non-biological mothers

DISCUSSION
The scientific production in the health sector in general regarding homo-parenthood appears to be an issue whose approach requires the understanding of socio-structural aspects that go beyond this field of knowledge.At least two of these aspects can be highlighted.The first of these concerns heteronormativity, which, in a hegemonic way, means thatconsciously or unconsciously-the first reference we have to family or parenting involves the union of a cis man with a cis woman.The existence of a homosexual couple means that this heterosexual norm is either reaffirmed to disqualify such a couple or deconstructed to accept homoaffective unions and parents.In this sense, it appears that much of the reviewed literature, before dealing with specific objects related to homoparenting, mentions the heteronormative context both as an explanatory model for the non-existence of specific health actions for lesbian or gay couples and as a dimension to be questioned or relativized as a unique reference to demand differentiated attention for these couples.
Another aspect that emerges in the reviewed scientific production, which covers issues that go beyond the health area in dealing with same-sex parenthood, refers to the legislation, or lack thereof, that ensures or prohibits not only the union of same-sex persons but also the desire of these persons to have children.Such aspects, directly or indirectly, are associated with the heteronormative context.We observed that, regarding legal aspects, there is great variability between countries and even within the states that make up a country.The absence of legal provisions, their incompleteness and/or dubiousness directly reflect on the way couples are assisted or are unable to access care.
Disclosing sexual orientation, both from the perspective of homosexual couples and from health professionals, emerges in the literature as something controversial.On the one hand, disclosure can contribute to specific health actions aimed at such couples.On the other hand, according to some studies, in the perception of lesbians and gays, disclosure can result in discrimination, invasive questioning, prejudice and even symbolic violence.The fear of disclosing homosexuality, in a certain way, can be linked to the heteronormative context and legal issues.
Scientific production on fertilization involves issues related to legislation, rights, access difficulties, absence or insufficient information, exclusion of non-biological homosexual mothers or fathers, prenatal care, childbirth, postpartum, and methods.The literature that deals with this topic focuses mainly on lesbians.In the balance made in the results of the studies, difficulties in accessing fertilization technology predominate.
Perceptions regarding attention to homoparenting, on the part of both homosexual couples and health professionals, are generally linked to the existence of dissatisfaction with the care received and negative attitudes on the part of those who should provide adequate care.
Regarding information and educational actions, the literature reports some positive experiences.However, these experiences compete with the perception that information is insufficient.Still in educational terms, there is an issue that crosses all the themes identified, explicitly or implicitly in the results: the lack of health professionals' preparation to deal not only with homo-parenthood, but also with homosexuality.
The revised collection constitutes a mosaic of themes that, directly or indirectly, are related to same-sex parenting.Each one of them, either by what is explicit or by inference of what is implicit, can provide principles for the field of collective health.In this sense, the results of this review are important, since they provide elements for, among other aspects, the organization of health services, the implementation of specific actions within the scope of promoting family health, and the adequate training of professionals to address gay and lesbian families.
It is also observed that the mapping obtained regarding the scope of the study is a starting point to expand the discussion about the central theme.This expansion may be more successful to the extent that, anchored in socio-anthropological references, it can problematize issues focused on different family arrangements and other conceptions of kinship that are not limited to consanguinity.
Finally, it is highlighted that, despite the vast collection identified, a limitation that can be pointed out for this review is language filtering, choosing only sources in Portuguese, Spanish, and English.Particularly noteworthy is the lack of studies in the French language, which gave rise to the term homo-parenthood.In addition to this, the bases chosen for the research may also have influenced the lack of studies in French.

CONCLUSIONS
Among the main conclusions it is worth highlighting that, although the national literature on homoparenting in the health sector is still timid, the international discussion seems to be relatively expanding.In terms of evidence, we can highlight that the scope of this review is not sufficiently problematized in health professionals' training and performance; and quantitative studies are smaller in number compared to those of a qualitative nature.This, although it brings us the specificities of the central theme, does not allow us to understand the extent of the problem highlighted in most studies.
Mapping the literature on the subject also revealed some gaps in the scientific production reviewed.In the context of collective health, it is worth highlighting the lack of studies focused on policies and programs and the absence of discussions on the health of children and adolescents from homo-parental families.
aspects Difficulty of access for homosexual couples Methods Male peers are more disadvantaged than female peers The legality of surrogacy varies in different countries Protocols on assisted reproduction do not cater for same-sex couples Regulation of in vitro fertilization makes access difficult for lesbians Priority for donor insemination techniques Prohibition of gay men donating sperm Future legal problems with the donor Measures for fertility services for homosexual couples General characteristics of primary studies.General characteristics of primary studies.Continuation https://doi.org/10.11606/s1518-8787.2023057005447Chart 1 .https://doi.org/10.11606/s1518-8787.2023057005447Chart 1 .https://doi.org/10.11606/s1518-8787.2023057005447